A nurse is caring for a client who has a chest tube that was inserted 4 days ago. Which of the following findings should the nurse report to the charge nurse?
Respiratory rate 16/min
Blood pressure 110/70 mm Hg
400 mL of drainage in the collection chamber within 4 hr
Fluctuation in the water seal chamber with respiration
The Correct Answer is C
A. Respiratory rate 16/min is a normal finding. A respiratory rate of 16/min is within the expected range for adults, so it does not indicate a problem that requires immediate attention.
B. Blood pressure 110/70 mm Hg is within the normal range for blood pressure. This is an acceptable finding and does not require reporting to the charge nurse.
C. 400 mL of drainage in the collection chamber within 4 hr should be reported to the charge nurse. This is an excessive amount of drainage for a client with a chest tube. After the first few hours post-surgery, the drainage should decrease. Large amounts of drainage may indicate bleeding, and it is important to notify the charge nurse immediately to assess the situation further.
D. Fluctuation in the water seal chamber with respiration is a normal finding. It is expected for the water seal chamber to fluctuate with the client’s respirations, indicating that the chest tube is functioning properly and the system is not obstructed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Chicken sandwich is correct. In kosher dietary practices, poultry such as chicken is allowed, as long as it is prepared according to kosher guidelines. It is permissible for a client who follows kosher dietary practices to have a chicken sandwich, provided the bread and other ingredients are also kosher.
B. Cheeseburger is incorrect. Kosher dietary laws prohibit mixing meat and dairy. A cheeseburger would violate this rule because it contains both meat (beef) and dairy (cheese..
C. Shrimp and french fries is incorrect. Shellfish, including shrimp, is not allowed in a kosher diet. Kosher dietary practices prohibit eating shellfish and other non-kosher seafood.
D. Bacon and eggs is incorrect. Pork products, including bacon, are strictly forbidden in kosher dietary practices, so this would not be an appropriate choice for a client following kosher dietary laws.
Correct Answer is A
Explanation
A. "It is your choice to share personal information during group therapy" is correct. The ethical principle of autonomy emphasizes respecting a client's right to make decisions about their own care, including the right to share or withhold personal information. Allowing the client to choose what to share supports their independence and decision-making ability.
B. "I will be truthful when answering questions about your treatment" promotes veracity, not autonomy. While truthfulness is important in nursing, it does not directly pertain to the principle of client autonomy.
C. "The nursing staff here will provide you with nonjudgmental care" promotes beneficence and respect for the client's dignity, but it does not directly address the principle of autonomy, which focuses on the client’s ability to make choices.
D. "I will only discuss your medical information with the health care team" supports confidentiality and privacy, not autonomy. Autonomy involves respecting a client’s decision-making, not just protecting their information.
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